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• The United States is not reaching the 70% national target rate for flu vaccination. • Flu vaccination varies greatly across race, socioeconomic status, and geography. • Rhode Island has implemented multiple strategies to promote flu vaccination. • Strategies include Medicaid expansion, Health Equity Zones, and state mandates. [ABSTRACT FROM AUTHOR]

Purpose: Colorectal cancer (CRC) diagnosis is associated with high mortality in the United States and thus warrants the study of novel treatment approaches. Vascular changes are well observed in cancers and evidence indicates that antihypertensive (AH) medications may interfere with both tumor vasculature and in recruiting immune cells to the tumor microenvironment based on preclinical models. Extant literature also shows that AH medications are correlated with improved survival in some forms of cancer. Thus, this study sought to explore the impact of AH therapies on CRC outcomes. Patients and Methods: This study was a non‐interventional, retrospective analysis of patients aged 65 years and older with CRC diagnosed from January 1, 2007 to December 31st, 2012 in the Surveillance, Epidemiology, and End‐Results (SEER)‐Medicare database. The association between AH drug utilization on AJCC stage I–III CRC mortality rates in patients who underwent treatment for cancer was examined using Cox proportional hazards models. Results: The study cohort consisted of 13,982 patients diagnosed with CRC. Adjusted Cox proportional hazards regression showed that among these patients, the use of AH drug was associated with decreased cancer‐specific mortality (HR: 0.79, 95% CI: 0.75–0.83). Specifically, ACE inhibitors (hazard ratio [HR]: 0.84, 95% CI: 0.80–0.87), beta‐blockers (HR: 0.87, 95% CI: 0.84–0.91), and thiazide diuretics (HR: 0.83, 95% CI: 0.80–0.87) were found to be associated with decreased mortality. An association was also found between adherence to AH therapy and decreased cancer‐specific mortality (HR: 0.94, 95% CI: 0.90–0.98). Conclusion: Further research needs to be performed, but AH medications may present a promising, low‐cost pathway to supporting CRC treatment for stage I–III cancers. [ABSTRACT FROM AUTHOR]

To combat risk selection, it is becoming increasingly common for payments to insurers (and providers) to adjust for patients' chronic conditions. A possible unintended negative consequence is to reduce insurers' (and providers') incentives to prevent chronic conditions. This study examined the effect of Medicare's risk adjustment for payments to Medicare Advantage plans, first introduced in 2004, on pneumonia and influenza vaccination for the elderly. The analysis used the 2000 through 2010 waves of the Medicare Current Beneficiary Survey and a difference-in-differences approach. Presumably by decreasing Medicare Advantage plans' positive influence on vaccination, Medicare's risk adjustment policy was estimated to have reduced pneumonia vaccination rates by 2.9 percentage points (4%, p = .039) and to have possibly reduced influenza vaccination rates by 2.2 percentage points (3%, p = .096). The results clarify an argument against including vaccine-preventable conditions, like pneumonia, in a risk adjustment model. [ABSTRACT FROM AUTHOR]

Objective: Much of the research on the effects of childhood adversity on mental health has focused on adults. The objective of our study was to examine the individual and cumulative effect of childhood adversity on mental health service use among children. Methods: We used data from the 2011-2012 National Survey of Children's Health (n = 79 834) to determine the use of mental health services in the past 12 months among children aged 2-17. The independent variables of interest were experiencing any 1 of 9 adverse family experiences (AFEs). We used logistic regression models to determine if each AFE was associated with mental health service use. We also examined AFEs as a continuous measure, representing the number of AFEs (ranging from 0 to 9) that summed them individually, and we examined age-by-AFE and age-by-need interaction terms. We adjusted all models for confounders. Results: Compared with not experiencing an AFE, experiencing all AFEs was associated with higher odds of mental health service use. Neighborhood violence was associated with the greatest increase in odds of mental health service use (adjusted odds ratio [aOR] = 2.35; 95% confidence interval [CI], 2.00-2.77). When measured as a continuous scale, each additional AFE was associated with higher odds of mental health service use (aOR = 1.33; 95% CI, 1.28-1.37). The effect of AFEs on mental health service use decreased with age. Conclusions: The observed association between AFEs and use of mental health services may be attributable to more severe or poorly managed mental illness among these children. Efforts are needed to increase access to and quality of mental health care among children affected by AFEs. [ABSTRACT FROM AUTHOR]

The article reports that enteral access to the stomach for feeding and medication delivery in patients with oropharyngeal dysphagia is achieved through nasogastric (NG) tube or gastrostomy tube such as percutaneous endoscopic gastrostomy (PEG). Topics include appropriateness and timing of obtaining enteral access via G-tube instead of NG tube; and Skilled nursing facilities have pointed to staffing issues, aspiration risk, lack of ability to check tube placement, concern for dislodgement.

The need to focus healthcare expenditures on innovative and sustainable health systems that efficiently use existing effective therapies are the major drivers stimulating Comparative Effectiveness Research (CER) across the globe. Lack of adequate access and high cost of essential medicines and technologies in many countries increases morbidity and mortality and cost of care that forces people and families into poverty due to disability and out-of-pocket expenses. This review illustrates the potential of value-added global health care comparative effectiveness research in shaping health systems and health care delivery paradigms in the "global south". Enabling the development of effective CER systems globally paves the way for tangible local and regional definitions of equity in health care because CER fosters the sharing of critical assets, resources, skills, and capabilities and the development of collaborative of multi-sectorial frameworks to improve health outcomes and metrics globally. [ABSTRACT FROM AUTHOR]

Objective: The introduction of novel therapeutic options for psoriasis has raised managed care's interest in controlling costs associated with dermatological treatments. Prior authorization (PA) can be a successful way of managing costs. However, experience with topical treatments for acne suggests that PA may not be cost-effective. The role of managed care in dermatology and the potential impact of PA requirements for novel topical therapies for psoriasis are considered. Methods: Using a model based on recent survey data, total annual cost estimates for a managed care organization to cover psoriasis treatment with a topical agent with or without PA requirements were calculated and compared. Costs for treatment and administrative costs associated with PA processes were included. The model assumed 68 000 insured patients required treatment (with an additional 1% to account for abuse/misuse), an average wholesale price of $100 per prescription (each prescription filled 4×/year), and a cost of $20 to process each PA request. Results: The total annual costs were $28 573 600 when PA was required and $27 472 000 when PA was not required. Thus, there was a total annual loss to the managed care organization of $1 101 600 associated with PA requirements. Conclusions: Requiring PA for novel topical treatments for psoriasis, such as the new two-compound product containing calcipotriene and betamethasone dipropionate (Taclonex®; Warner Chilcott (US), Inc.; marketed as Daivobet®/Dovobet® outside US by LEO Pharma), is not likely to be cost-effective for a managed care organization. [ABSTRACT FROM AUTHOR]

Objective: To examine the prescribing patterns of topical retinoids in the United States. Methods: A retrospective, cross-sectional study was employed. Data from the National Ambulatory Medical Care Survey (1990-2004) were used. The impact of patient diagnosis of acne and other covariates on the probability of getting a retinoid prescription was examined using weighted multivariate logistic regression models. Results: Among the national cohort of patients aged 10 years and older (number of patient visits = 11.7 billion), 41.5 million patients received a topical retinoid prescription. In the retinoid cohort, more than 70% of patients had a diagnosis for acne vulgaris. Diagnosis of acne vulgaris was the strongest predictor of getting a retinoid prescription after controlling for other covariates (OR: 43.39; 95% CI: 32.44, 58.02). Conclusions: Requiring prior authorization for topical retinoids for all age groups seems unwarranted and may not be cost-beneficial for the managed care organizations based on these and previous findings. [ABSTRACT FROM AUTHOR]

Background: Vigilant reporting of medication errors and adverse drug events (ADEs) is needed to understand and reduce the extent of this problem in dermatology. Various systems are already in place in inpatient settings. Objective: To review existing medication error reporting systems related to outpatient settings with emphasis on topical medications associated with dermatological diseases. Method: Search terms 'medication error', 'outpatient settings', 'barriers', 'medication use process', 'CPOE' (computerized prescriber order entry), 'dermatological conditions' and 'skin disorders' were used. Results: The rate of medication-related incidents range as high as 4.49 per 1000 to 24.1 per 1000 inpatient days. The most common error type was patient error, accounting for 56% of errors. Other errors that occurred were prescription errors (13%), delivery errors (13%), availability errors (10%), and reporting errors (8%). CPOE systems can increase medication safety, while introducing other problems including faulty computer interface, miscommunication with other systems, lack of adequate decision support, and other human errors (knowledge deficit, distractions, inexperience, and typing errors). Conclusion: There is an opportunity for improved tracking and reporting of medication errors in dermatology. Systems are needed to ensure that patients understand how their medication should be used. [ABSTRACT FROM AUTHOR]

Our understanding of the world around us is derived from our observations. The accuracy of our inferences depends on the representativeness of those observations. Selection bias limits the accuracy of our inferences. Systematic selection bias occurs when the particular outcome observed caused the observation; this type of bias can lead to dramatic errors in inference. We describe examples of selection bias, provide a mathematical formulation of the systematic selection bias phenomenon, and discuss how biased observations may affect people's impressions of important issues in dermatology. [ABSTRACT FROM AUTHOR]

Maintenance of symptom control in Parkinson's disease (PD) requires continuous titration of medication and addition of multiple therapies over the course of the disease. Adherence to medication is vital to symptom control and key to maximizing the efficacy of existing therapies. However, adherence is compromised by a variety of factors, including motor symptoms, complex dosing regimens, multiple medications, and lack of patient/physician awareness of the impact and prevalence of suboptimal adherence. This retrospective, longitudinal cohort study assessed the prevalence of suboptimal adherence [measured as the medication possession ratio (MPR)] to PD medications, and its impact on the worsening of PD symptoms (measured as increase in monotherapy dose, augmentation of therapy, PD-related emergency department visit, or hospitalization), in a Medicare Health Maintenance Organization population in the United States. Irrespective of the MPR threshold chosen, a high percentage of patients were categorized as suboptimally adherent to their PD medications, and patients with suboptimal adherence to their PD medications had higher risks of worsening of PD symptoms, compared with those who were adherent. Increased awareness of both the magnitude and impact of suboptimal adherence to PD medications, coupled with dosage simplification and a unified effort by healthcare professionals and patients, may improve adherence to PD medications and ultimately improve symptom control. © 2007 Movement Disorder Society [ABSTRACT FROM AUTHOR]

Abstract: Background: Outcomes in patients with type 2 diabetes mellitus (DM) can differ based on the antidiabetic medication that is used. Thiazolidinediones (TZDs) are a newer class of agents used for the treatment of type 2 DM. No previous study has compared health care utilization associated with the 2 TZDs on the market. Objective: The objective of this study was to compare health care utilization and costs associated with initiation of treatment with either rosiglitazone or pioglitazone by Medicaid-enrolled patients with type 2 DM. Methods: This was a retrospective data analysis comparing cohorts of patients with type 2 DM starting a new antidiabetic medication in terms of hospitalizations, emergency department visits, outpatient physician visits, and health care costs reimbursed by the North Carolina Medicaid program. The perspective adopted in this analysis was that of the third-party payer (ie, the North Carolina Medicaid program). Patients starting rosiglitazone between July 1, 2001, and June 30, 2002, were compared with patients starting pioglitazone during the same period. The patients were followed up for 30 months to examine the difference in health care utilization over time. Multivariate regression techniques were employed for comparisons between the 2 different antidiabetic therapies. Results: A total of 1705 patients with type 2 DM were identified and included in the final cohort. There were 660 patients (mean [SD] age, 49.0 [10.2] years) in the rosiglitazone arm and 1045 patients (mean [SD] age, 49.1 [10.5] years) in the pioglitazone arm. Multivariate analysis showed that the rosiglitazone monotherapy group was associated with a 12.2% decrease in the mean number of hospitalizations, a 10.4% decrease in the mean number of emergency department visits, and a 7.3% decrease in total health care costs compared with the pioglitazone monotherapy group (all, P < 0.05). This study only looked at patients who used the same drug for the entire follow-up period. It did not account for drug switching or addition of a new drug to an existing therapy. Conclusions: Introduction of rosiglitazone was associated with a decreased number of hospitalizations, emergency department visits, and total health care costs compared with pioglitazone. The utilization of oral antidiabetic agents, with documented clinical and economic benefits, should continue to be advocated to reduce avoidable medical care utilization and to improve patient outcomes in this population. [Copyright &y& Elsevier]

Abstract: Objective:: The aim of this study was to compare treatment adherence and health care costs in African Americans versus all other races (All Others) in patients with type 2 diabetes mellitus starting treatment with pioglitazone. Methods:: In this retrospective cohort study, the North Carolina Medicaid database was used (query dates: July 1, 2000, to June 30, 2003). Using at least 1 code from the International Classification of Diseases, Ninth Revision, Clinical Modification for type 2 diabetes (250.xx) and 1 National Drug Code for antidiabetic medication, we identified a cohort of male and female patients aged ≥18 years with type 2 diabetes who maintained continuous Medicaid eligibility for the entire 36-month follow-up period. Race was categorized as African American and All Others (white, Asian, Native American, Pacific Islander, other) based on self-reported data collected at the time of Medicaid enrollment. Medication adherence was expressed as medication possession ratio (calculated as the number of days of antidiabetic prescription supply dispensed [eg, a 30-day supply] divided by the number of days between the first and last dispensation). Reimbursements made by Medicaid were used to calculate diabetes-related and total health care costs, which included medical and dental care, including costs for regular checkups, office visits, home health care, inpatient and outpatient care, long-term care facility care, and prescription drugs. To compare the differences in medication adherence and annual total and diabetes-related health care costs between African Americans and All Others, multivariate regression analysis was performed using only data from the year after (year 2) the year in which pioglitazone treatment was started (year 1). Results:: Among the 1073 patients treated with pioglitazone (26.1% men; mean [SD] age, 49.5 [10.6] years; 50.2% African American; mean [SD] total health care costs in year 1, US $7906 [$12,256]; year 2, $9546 [$14,861]), African Americans had significantly higher adherence (62%) to pioglitazone treatment compared with All Others (57%) (P < 0.05) on unadjusted analysis. However, no significant differences in rates of adherence to the medication were found between African Americans and All Others on multivariate regression analysis. African American race was not found to be an independent predictor of increased or decreased annual total health care costs in this population. Significant reductions in total health care costs (2% for every 10% increase in adherence; P < 0.001) and diabetes-related costs (4% for every 10% increase in adherence; P < 0.01) with increased adherence were found. Conclusions:: On multivariate analysis, this study found no significant differences in treatment adherence between African Americans versus all other races in this population of diabetic patients enrolled in a Medicaid program (query dates: July 1, 2000, to June 30, 2003). A higher adherence rate was associated with significantly lower diabetes-related and total health care costs in this population. [Copyright &y& Elsevier]

Objectives : Actinic keratoses (AKs) are common skin lesions with the potential to progress to squamous cell carcinoma. Many effective treatment alternatives exist, yet the reasons for treatment choice have not been explored. This study examined which AK therapy was preferred among dermatologists and primary care physicians (PCPs), as well as potential determinants of therapeutic selection. Methods : A random national sample of 534 dermatologists and PCPs selected from the American Medical Association database completed AK questionnaires. The final sample included 1184 AK patients treated by dermatologists and 559 AK patients treated and/or referred by PCPs. All analyses were weighted using the survey sampling weights. Results : Patients who had new and recurring lesions as well as patients who had a mean duration of more than a year since the last AK episode treatment (all p [ABSTRACT FROM AUTHOR]

Background Facial appearance plays a large role in self-perception and interaction with others. Visible facial skin lesions are a common condition. Purpose This study assessed factors associated with health-related quality of life (HRQOL) in women with visible facial skin lesions. Methods The study included 73 women with one or more of the following conditions: acne, dermatosis papulosis, hypopigmentation, lentigenes, melasma, rosacea, vascular proliferations and other facial scars. The Skindex-16 was used as a measure of HRQOL. Fear of negative evaluation (FNE) was assessed to determine whether self-perception characteristics relate to HRQOL. Results There were strong correlations in both bivariate and multivariate analyses among increased FNE, heightened perception of QOL without the facial condition and lower overall HRQOL ( P < 0.05 and P < 0.01, respectively). There were no differences in HRQOL by type of facial condition, as well as no effects of the area covered by the condition on HRQOL. Interestingly, women not using foundations represented only 10% of the study population and had better HRQOL than women who did use foundations. Conclusions Severe facial blemishes of any cause have a significant impact on women's QOL, and the effect of these lesions is mediated in part by psychological characteristics related to self-perception and self-presentation. [ABSTRACT FROM AUTHOR]

Background: Development of managed care, characterized by limited provider choice, is believed to undermine trust. Provider choice has been identified as strongly associated with physician trust. Stakeholders in a competitive healthcare market have competing agendas related to choice. The purpose of this study is to analyze variables associated with consumer's satisfaction that they have enough choice when selecting their primary care provider (PCP), and to analyze the importance of these variables on provider trust. Methods: A 1999 randomized national cross-sectional telephone survey conducted of United States residential households, who had a telephone, had seen a medical professional at least twice in the past two years, and aged = 20 years was selected for secondary data analyses. Among 1,117 households interviewed, 564 were selected as the final sample. Subjects responded to a core set of questions related to provider trust, and a subset of questions related to trust in the insurer. A previously developed conceptual framework was adopted. Linear and logistic regressions were performed based on this framework. Results: Results affirmed 'satisfaction with amount of PCP choice' was significantly (p < .001) associated with provider trust. 'PCP's care being extremely effective' was strongly associated with 'satisfaction with amount of PCP choice' and 'provider trust'. Having sought a second opinion(s) was associated with lower trust. 'Spoke to the PCP outside the medical office,' 'satisfaction with the insurer' and 'insurer charges less if PCP within network' were all variables associated with 'satisfaction with amount of PCP choice' (all p < .05). Conclusion: This study confirmed the association of 'satisfaction with amount of PCP choice' with provider trust. Results affirmed 'enough PCP choice' was a strong predictor of provider trust. 'Second opinion on PCP' may indicate distrust in the provider. Data such as 'trust in providers in general' and 'the role of provider performance information' in choice, though import in PCP choice, were not available for analysis and should be explored in future studies. Results have implications for rethinking the relationships among consumer choice, consumer behaviors in making trade-offs in PCP choice, and the role of healthcare experiences in 'satisfaction with amount of PCP choice' or 'provider trust.' [ABSTRACT FROM AUTHOR]

Background: Recent data from the pharmaceutical industry suggest that generic medications are occupying an increasing percentage of the prescription drug market. Objective: The objective of this paper was to review the trends in branded and generic dermatological and overall medications in the United States. Methods: A thorough literature search of research papers for the period 1990–2003 was performed. In addition, we utilized data from a number of medical databases to obtain and compare information on the manufacturing, production, patents and prescription of branded and generic drugs. Results: Two of the top 10 drugs used exclusively for dermatological conditions prescribed in 2003 were generics. For all drugs, the number of generic equivalents increased from 2 (in 1990) to 6 (in 2003) of the top 10 prescription drugs. Conclusions: The economic, social and scientific implications of the rising prominence of generic drugs are incredibly complex. Dermatologists, pharmacists, pharmacy benefit managers, and health policy makers should consider medication decisions carefully. [ABSTRACT FROM AUTHOR]

Aim: To describe trends in the prescription of medication for acne vulgaris in the USA from 1990 to 2002 with particular reference to the shift from antibiotic to non-antibiotic treatment. Methods: Retrospective cross-sectional observational study which analysed the data from the 4922 patient visits for acne vulgaris from the 1990-2002 National Ambulatory Medical Care Survey (NAMCS) to assess medications mentioned or prescribed at office visits for acne vulgaris. We specifically analysed visits for benzoyl peroxide or combination benzoyl peroxide products, topical retinoids, clindamycin, erythromycin, tetracycline group antibiotics and isotretinoin. A priori predictions were made for changes in physician behaviour over time, and were tested by regression. Multivariate regression also assessed the impact of demographic variables such as patient age, gender, race and type of physician seen on prescribing behaviour. Results: From 1990 to 2002 there were significant declines (p<0.01) in the likelihood of use of several drug classes that are reliant on antimicrobial mechanisms for acne including the following: benzoyl peroxide, topical clindamycin, oral erythromycin and tetracycline group antibiotics. There were significant increases in likelihood of utilization for agents not reliant on antimicrobial mechanisms including topical retinoids and oral isotretinoin during this period. These changes in utilization were not affected by controlling for demographic factors in multivariate analysis. Conclusion: There has been a shift towards non- antibiotic treatment in acne management. Growing awareness of antibiotic-resistant Propionibacterium species may contribute to increased use of topical and systemic retinoid agents. [ABSTRACT FROM AUTHOR]

Atopic dermatitis is a common disease of increasing prevalence. Affected individuals must cope with a significant psychosocial burden, in addition to dealing with the medical aspects of the disease. Furthermore, because this is primarily a disease of childhood, family members, especially parents, are also affected by the condition. Individuals and family members are burdened with time-consuming treatment regimens for the disease, as well as dietary and household changes. The financial impact of atopic dermatitis on families can also be great. Moreover, the cost to society is significant, with estimates ranging from less than$100 to more than$2000 per patient per year. It is estimated that the direct cost of atopic dermatitis in the United States alone is almost$1 billion per year. Reducing the onus of this disease must take into account the full breadth of its burden. Targeting parents and caregivers with education and psychosocial support can decrease family and personal burden, which in turn may decrease the cost of treating the condition because of better medical, psychosocial, and family outcomes. [ABSTRACT FROM AUTHOR]

Background. Outcomes in asthmatic patients may vary depending on the controller medication used. Observational studies of outcomes of asthma therapy are needed to understand the implications of choice of controller in different populations. Objectives. To determine whether there are differences in health care use and costs of asthma treatment in asthma patients treated with montelukast compared with fluticasone proponiate 44 µg. Method. Using data from the North Carolina Medicaid program, we compared continuously enrolled asthmatic patients starting either fluticasone propionate 44 µg (FP44), an inhaled corticosteroid (ICS) (n = 312), or montelukast 5 and 10 mg, an oral leukotriene modifier (LM) (n = 398) between the years 1998 and 1999. A secondary analysis compared continuously enrolled asthmatic patients already using ICS as controller therapy initiating either salmeterol (long-acting ß-agonist) (n = 97) or montelukast (n = 101) in the year 1998. Patients were followed for 1 year pre- and postcontroller or additional controller initiation for health care service use, medication refill patterns, and costs. Results. There were no significant differences in the adjusted asthma-related health care costs between the montelukast and FP44 groups. In both groups, physician visits were significantly higher in year 2 (p [ABSTRACT FROM AUTHOR]

Scant evidence exists that examines the impact of participation in primary care diabetes managementprograms and their educational components on the risk of subsequent significantpatient morbidity. This study examined the association between participation in a diabetesmanagement program in a primary care setting and the risk of subsequent hospitalization.Ten thousand nine hundred eighty patients with diabetes mellitus receiving some type oftreatment in a large primary care clinic network in Houston, TX were examined for incidenceof hospitalization in the year 2002. Information from the year preceding the hospitalizationwas obtained on several demographic, clinical, and diabetes care management participationrelated variables. Multivariate logistic regressions were used to examine the relationship betweenprimary care diabetes management participation as well as individual educational componentsand the likelihood of subsequent-year hospitalization. Patients participating in sometype of primary care diabetes management were 16% less likely to have an incidence of hospitalization(= 0.05). When individual educational components of the diabetes care managementprogram were examined, diabetes education sessions were more beneficial than certifieddiabetes educator visits in reducing the incidence of hospitalization. Patients withcontrolled blood glucose levels and a diabetes education session seemed to have the most significantreduction in hospitalization risk (odds ratio [OR] = 0.62; 95% CI: 0.40, 0.95). Thereseem to be beneficial effects associated with participation in primary care diabetes managementprograms in terms of reduced hospitalization risk. Attendance at diabetes educationalsessions in primary care settings coupled with maintenance of blood glucose control seem tobe associated with greatest risk reduction. (Disease Management 2004:325–332) [ABSTRACT FROM AUTHOR]

Background: Combination treatment in psoriasis may be common, logical, and appropriate, even if not well tested or well documented by clinical trials. While oral retinoids such as acitretin can be used as monotherapy, efficacy can be further augmented by combination use with other agents. Similarly, because of its safety profile, acitretin can be added in low doses to help patients who have not achieved adequate control with other psoriasis treatments. Objective: The purpose of this study was to assess how oral retinoids are used in combination with other drugs to treat psoriasis. Methods: We assessed the use of acitretin and other oral retinoids for the treatment of psoriasis using two sources of information: nationally representative survey data from the National Ambulatory Medical Care Survey (NAMCS) and local data obtained by chart review of 518 patients seen in a university dermatology clinic. Results: In the NAMCS, oral retinoids were prescribed with other psoriasis medications at 71% of visits. In the chart review, combination use was even more frequent (96% of subjects were on combination treatment) and included combinations of acitretin with topicals, phototherapy, and other systemic treatments. Adverse events were reported in 53% of patients treated with acitretin, although none were severe. Conclusion: Use of acitretin in combination with many other psoriasis treatments is a common practice. Mucocutaneous side effects of oral retinoids are common but with appropriate dosing are generally mild. [ABSTRACT FROM AUTHOR]

Most studies of trust in the medical arena have focused on trust in physicians rather than trust in health insurers, and have been cross-sectional rather than longitudinal studies. This study examined associations among trust in a managed care insurer, trust in one's primary physician, and subsequent enrollee behaviors relating to source of care. The study also documents changes in trust in the study population following the disclosure of physician incentives. A medium-sized (300,000 member) HMO, located in the southeastern United States. One to two years after baseline, we randomly resurveyed a quarter ( n=558) of the initial study population of a large intervention study designed to measure the impact of disclosing HMO financial incentives on patient trust. This follow-up study was also designed to measure the effects of trust on source of care. Multivariate regression analyses of survey data examined associations between baseline levels of trust and subsequent enrollee behaviors such as using a non-PCP physician without a PCP referral, as well as changes in trust since baseline. High baseline insurer trust was associated with a lower probability of a patient seeking care from a non-PCP physician (OR=0.55, 95 percent CI: 0.33, 0.91). No long-term effects of prior disclosure of financial incentives were observed. Overall, there was a slight increase in overall trust in the insurer (1.8 percent, p<.05) but no change in trust in one's primary physician. The increase in insurer trust was primarily restricted to 23 percent of the enrollees who had changed their PCPs following the baseline survey (6.6 percent, p<.01). In multivariate analyses, changing physicians was the most significant predictor of increased insurer trust (OR=2.17, 95 percent CI: 1.37, 3.43). Trust in one's insurer seems to change over time more than trust in one's primary physician, and is predictive of enrollee behaviors such as seeking care from other physicians. The ability to change physicians seems to increase trust in the insurer. [ABSTRACT FROM AUTHOR]

Background: Patients' trust in physicians and in the medical profession is vital for a successful patient-physician relationship. Trust is especially salient in critical medical situations, such as serious side-effects, hospitalizations, and diagnoses of serious medical conditions, but most trust studies have been done with the general population or in routine primary care settings. This study examines the association between patient-physician encounters in such critical medical situations and patients' trust in their physician and in the medical profession in general. Methods: A random national telephone survey was conducted using validated multi-item questionnaire measuring trust and satisfaction with physicians and with the medical profession. A seven item questionnaire measured the patient-physician encounters in critical medical situations. A total of 1117 subjects aged 20 years and older with health insurance were included for analyses. Spearman rank order correlations were used to determine the association of encounter variables with trust in physicians and the medical profession. Results: Prescription of medications by primary care physicians that patients believed might have side effects was negatively correlated with trust in physician (ρ = -0.12, p < 0.001, n = 1045) in multivariate analysis. A primary care physician evaluating the patient for a condition the patient believed was serious was positively correlated with trust in physician (ρ= 0.08, p < 0.01). Being hospitalized was positively correlated with trust in the medical profession (ρ = 0.12, p < 0.01, n = 475). Conclusion: Hospitalization, perceived seriousness of condition, and concerns about the risks of medications were found to be associated with patient trust in physicians or the medical profession. These findings highlight the salience of trust in serious physician-patient encounters and the role that patient vulnerability plays in determining patient trust. [ABSTRACT FROM AUTHOR]

Background: The cost of treating diabetes mellitus and its complications is high ($91.8 billion in the United States in 2002). It is important to understand predictors of adherence to therapy with different antidiabetic medications and to determine the relationships between adherence and health care service utilization in older adults (aged ≥65 years) with type 2 diabetes mellitus.Objective: The aim of this study was to examine the relationship between self-reported health status data, subsequent antidiabetic medication adherence, and health care service utilization in older adults with type 2 diabetes mellitus in a managed care setting.Methods: This was a longitudinal cohort study of older adults in the south-eastern United States with type 2 diabetes mellitus who completed a health status assessment, used antidiabetic medications, and were enrolled in a health maintenance organization (HMO) continuously for 1 to 5 years. The baseline assessment included questions related to demographics, health care service utilization in the year before enrollment, lifestyle, and quality of life. Demographic, clinical, and utilization-related economic variables were also retrieved from the administrative claims data of the patients'' HMO. Prescription refill patterns were used to measure adherence. Associations were examined with a sequential, mixed-model, regression approach. Model appropriateness was tested via sensitivity analyses with logged and unlogged dependent variables.Results: A total of 775 patients were included. Increased comorbidity severity and an emergency room visit during the year prior to enrollment in a Medicare HMO were independently associated with decreased antidiabetic medication possession ratios (MPRs) after enrollment. After controlling for type of medication therapy and other variables, increased antidiabetic MPR remained the strongest predictor of decreased total annual health care costs (8.6% to 28.9% decrease in annual costs with every 10% increase in MPR; P < 0.001). Adherence to anti-diabetic medications was a greater driver of cost reduction than other concurrent medications (eg, statins) in this population.Conclusions: This study found strong associations between decreased anti-diabetic medication adherence and increased health care service utilization in older adults with type 2 diabetes mellitus in a managed care setting. Health status assessments completed at time of enrollment had the potential to identify enrollees with higher risk for both nonadherent behaviors and poor health-related outcomes. [Copyright &y& Elsevier]

Because of recent press reports of adverse outcomes, office-based cosmetic surgery has come under intense scrutiny and associated legislative regulatory action. To assess the safety of office-based cosmetic surgery through a national survey of state agencies that collect information on adverse patient outcomes. Medical boards or other responsible authorities were contacted in 48 states to obtain records on adverse outcomes from cosmetic surgery procedures performed in an office-based setting. Five states were able to provide complete information regarding 13 cases of adverse outcomes that resulted from office-based cosmetic surgery procedures. Thirteen states had incomplete information or were unable to provide information. The remaining states reported no adverse outcomes. Information collected by state agencies varies greatly and is inadequate to define the safety of office-based cosmetic surgery practice. The need to regulate physician office surgery on the basis of hospital privileges and office certification is not supported by current data. Mandatory reporting of adverse outcomes from office-based surgery is warranted to identify modifiable risk factors and to reduce the risk of adverse outcomes. R. BALKRISHNAN, PHD, I. K. GILL, J. A. VALLEE, AND S. R. FELDMAN, MD, PHD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. [ABSTRACT FROM AUTHOR]

Although some preliminary work exists examining the impact of atopic dermatitis (AD) in children on their families, there is no empirical work examining specific parent caregiver factors that could contribute to the family impact of this condition. We conducted a cross-sectional, exploratory analysis of how parent caregivers are affected by their child's AD, and how certain parent caregiver characteristics and perceptions affect the family impact of this condition. Parent caregivers of children with AD (n = 49) were administered a survey to collect detailed data on socioeconomic status, health perceptions, and caregiving issues. Family impact of the child's AD was measured using a modified AD Family Impact Scale. Multiple regression analyses revealed that three major factors associated with the parent caregiver were correlated with large increases in the family impact scores: 1) perception that the child's condition is severe (13%, p < 0.01), 2) high use of nonmedical services for child's condition (21%, p < 0.01), and 3) financial concern about the child's condition (18%, p < 0.01). These preliminary data indicate distinct characteristics of the parent caregiver that are associated with higher family impact of AD in children. These parent caregiver factors may be important in identifying suitable audiences and areas for education for optimal management of children's AD. [ABSTRACT FROM AUTHOR]

An increasing number of media reports on patient safety risks arising from office-based surgery procedures, as well as growing concerns about patient safety issues in general, have brought office-based surgery as well as its practitioners into focus and placed this very cost-effective medical practice in the eye of the media and regulators. Concerted efforts are now being made to understand the causes and true incidence of patient safety risk associated with office-based surgery and to find ways to minimize this risk. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the relationship between self-reported health status, prophylactic medication use, and healthcare service use in older adults with asthma. DESIGN: A prospective longitudinal cohort study was conducted over a 2-year postenrollment period in a population of asthmatic older adults enrolled in managed care. Patients completed a comprehensive health-risk screen at time of enrollment in the plan. SETTING: A Medicare health maintenance organization (HMO) in the southeastern United States with prescription benefit. PARTICIPANTS: One hundred twenty-nine older adults with asthma using inhaled corticosteroid therapy as prophylaxis and enrolled in a Medicare HMO were available for complete follow-up. MEASUREMENTS: We measured self-reported health perception, falls, lifestyle, depressive symptomatology, and pre-enrollment healthcare service use using a comprehensive risk screen. We used the Med-Total index and total annual healthcare charges as measures of postenrollment inhaled corticosteroid and healthcare service use. RESULTS: After adjusting for the effects of other variables, we found that depressive symptomatology at baseline and increased comorbidity severity (using the Charlson comorbidity index) were associated with significant reductions in prophylactic medication possession (27% with depressive symptomatology and 6% with unit increase in Charlson's index, P < .05). Additionally, after adjusting for the effects of baseline health status, we found that a 10% increase in prophylactic medication possession was associated with a nearly 5% decrease in total annual healthcare charges in this population (P < .01). CONCLUSION: There are strong but not fully explained associations between depressive symptoms at time of enrollment, decreased postenrollment prophylactic medication use and increased postenrollment healthcare service use in older adults with asthma. [ABSTRACT FROM AUTHOR]

This study examined associations between select hypothesized adherence predictors in claims databases and long-term inhaled corticosteroid adherence. Medication adherence was measured by using medication possession indexes and a refill regularity measure in 1595 older adults using inhaled corticosteroids for 2 years. Medication possession indices were highly correlated with each other but not with the refill regularity measure. Additionally, the hypothesized predictors explained a larger percentage of the variance in the medication possession indices compared to the refill regularity measure. Although long-term retrospective medication utilization poses many measurability issues, the use of multiple indices gives a more complete picture of usage behavior. [ABSTRACT FROM AUTHOR]

Annual preventive care is essential for diabetes patients to reduce the risk of complications including hypoglycemic events and blindness. Our aim was to examine the relative efficiency of Diabetes Belt (DB) and non-Diabetes Belt (NDB) counties in providing recommended preventive care for Medicare beneficiaries with diabetes using available health professional resources and to understand county-level socioeconomic factors associated with inefficient provision of preventive care. A data envelopment analysis (DEA) model was developed to assess relative efficiency of counties in providing diabetes preventive care. Logistic regression was performed to identify socioeconomic characteristics associated with inefficiencies. We used Medicare claims data to extract individual-level information of diabetes preventive service use and obtained county-level estimates of health resources information from the Area Health Resources File. More than 80% of counties had more than 10% inefficiencies on average. Compared to counties in the NDB, the odds of being inefficient were 2.44 times more likely in the DB (OR 2.44, CI 1.67–3.58). Counties with lower median income, with a smaller proportion of non-Hispanic Black population, and in a rural area had higher odds of being inefficient in providing preventive care. Our DEA results showed that counties in the DB and NDB were mostly inefficient. The availability of care providers may be less of a problem than how efficiently the resources are used in providing preventive care. Identifying sources of inefficiency within each community with low resource utilization and developing targeted strategies is needed to improve uptake of preventive care cost-effectively. [ABSTRACT FROM AUTHOR]

Background: Treatment adherence to home phototherapy is not well characterized. Purpose: To develop an accurate measure of home phototherapy unit usage. Methods: We tested a commercially available data logger containing a photo-sensor on two home phototherapy units. Results: The data logger accurately recorded actual usage and did not record stray light sources over the study period. Conclusion: A data logger can accurately capture usage patterns for a home phototherapy unit. These devices could potentially be used in clinical trials to measure adherence to home phototherapy treatment regimens. [ABSTRACT FROM AUTHOR]

Background: To achieve optimal resource allocation in health care, it is necessary to value competing resource uses according to the benefit derived from those uses. Skin disease makes as great an impact as other serious medical conditions when assessed by effects on health-related quality of life. Objective: To confirm the high impact of skin disease by comparing patients’ willingness to pay (WTP) to be cured or relieved from symptoms of skin and nonskin conditions. Methods: We searched the published literature on WTP to compare the impact of dermatologic conditions with the impact of other medical conditions. A total of 46 articles were identified of which 10 included information on willingness to pay for cure reported on a monthly basis. Results: WTP for skin diseases fell in the range of $125–260/month and was comparable or higher than all but one of the other identified conditions. Conclusion: Willingness to pay for relief from skin diseases is comparable to that for relief of other serious medical conditions. Skin diseases are associated with a significant adverse impact on patients’ lives. [ABSTRACT FROM AUTHOR]

PURPOSE: A key challenge regarding the current opioid epidemic is understanding how concerns regarding opioid-related harms affect access to pain management, an essential element of cancer care. In certain regions of the United States where disproportionately high cancer mortality and opioid fatality rates coexist (such as southwest Virginia in central Appalachia), this dilemma is particularly pronounced. METHODS: This longitudinal, exploratory, secondary analysis used the Commonwealth of Virginia All Payer Claims Database to describe prescription opioid medication (POM) prescribing patterns and potential harms for adult patients with cancer living in rural southwest Virginia between 2011 and 2015. Descriptive and inferential statistical analyses were conducted at the patient, prescriber, and prescription levels to identify patterns and predictors of POM prescribing and potential harms. To explore geographic patterns, choropleth and heat maps were created. RESULTS: Of the total sample of patients with cancer (n = 4,324), less than 25% were prescribed a Controlled Substance Schedule II POM at least three times in any study year. More than 60% of patients never received a Controlled Substance Schedule II POM prescription. Six hundred fifty-two patients (15.1%) experienced 1,599 hospitalizations for any reason; 10 or fewer patients were admitted for 11 opioid use disorder–related hospitalizations. The main findings suggest potential undertreatment of cancer-related pain; no difference in risk for opioid-related hospitalization on the basis of frequency of POM prescriptions; and geographic disparities where opioid overdoses are occurring versus where POM prescription use is highest. CONCLUSION: These findings have significant opioid policy and practice implications related to the need for cancer-specific prescribing guidelines, how to optimally allocate health delivery services, and the urgent need to improve data interoperability and access related to POMs. [ABSTRACT FROM AUTHOR]

Understanding the patterns of antihypertensive drug use and blood pressure (BP) control among stroke survivors in the "real-world" setting is important to identify gaps in treatment and control, if any. The objective of our study was to assess trends and patterns in antihypertensive drug use and BP control among stroke survivors in the United States. We performed a retrospective cross-sectional analysis of the 2003-2014 National Health and Nutrition Examination Survey (NHANES). Stroke and hypertension diagnoses were self-reported. Information regarding the use of antihypertensive drugs was collected during an in-person interview. Measurement of BP was performed by trained medical professionals in mobile examination centers. A total 1244 adult stroke survivors (equating to 6 232 215 stroke survivors nationwide) were identified, of which 956 had hypertension. Antihypertensive drug use increased from 2003 (79.5%) to 2014 (92.2%; P for trend < 0.001). The prevalence of drug use was lower (52%) among survivors aged 20-39 years compared with older age groups. Use of ≥2 antihypertensive drugs was prevalent (63.8%), but diuretics alone or in combination with angiotensin-converting enzyme inhibitors were underutilized (22.4%). More than one-third of the survivors were not at BP goal (ie, BP < 140/90 mm Hg). Males were more likely to attain BP goal than female stroke survivors (odds ratio [OR] = 2.02; 95% CI: 1.34-3.05). Our findings suggest that despite improvements in antihypertensive drug use in the recent years, BP is not adequately controlled in a significant proportion of stroke survivors. Further research focusing on understanding the reasons for unmet BP goal in stroke survivors is needed. [ABSTRACT FROM AUTHOR]

The authors reflect on the impact of psoriasis on patient's lives. According to the authors, the distress of psoriasis does not inevitably imply a good treatment adherence to medication. The authors assert that the tendency for patients to use their medication well may be an incorrect assumption. In addition, the authors maintain that the poor quality of life linked with psoriasis is not associated with better adherence and suggest patients to choose a treatment they are willing to use.

Psychotropic medications are a common treatment for mental illness in people with developmental disabilities. Medication adherence is a critical determinant of the effectiveness of psychotropic drugs, but psychotropic medication adherence research specific to this population remains limited. This retrospective study analyzed Marketscan® Multi-State Medicaid Database 2003–2007 data. A total of 3,905 eligible community-based Medicaid enrollees aged 18–64 with dual diagnosis of developmental disability and mental illness were included and followed over an average of 510 days. Medication adherence was measured by Proportion of Days Covered (PDC), and logistic regression was used to assess factors associated with adherence. The mean PDC was 0.86, and the non-adherence rate was 25.7%. Factors associated with poor psychotropic medication adherence included minority race/ethnicity, female gender, enrollment in a Medicaid capitated plan, and having gastroesophageal reflux disease (GERD). Better psychotropic medication adherence was related to reductions in emergency room visits, suggesting better utilization outcomes. [ABSTRACT FROM AUTHOR]

Atopic Dermatitis (AD) is a chronic inflammatory skin disease that is broadly characterized by eczematous lesions and pruritus. This condition is detrimental in a multitude of ways, including patient quality of life (QOL), family QOL, economic burden, and psychosocial afflictions. Current management needs to incorporate a holistic approach which considers the financial, emotional, and physical limitations of both the treatments and the provider. A non-systematic search was conducted on the holistic management of pediatric AD. Various search queries were used such as the key terms of "atopic dermatitis," "pediatric," "eczema," "management," and more to encompass treatments, adherence, and comorbidities. There is an association with AD and depression in children, and its prevalence should be screened for routinely in children with AD. Collaboration with other specialties may prove to be prudent in addressing this comorbidity. Objective quality of life scores can open the door to much needed conversation with patients to get them the help they need. In expanding our scope, we find the extended consequences of AD have a ripple effect on families of pediatric patients. Lastly, we introduce a model for improving treatment adherence. Conclusion: Patient quality-of-life can be negatively affected by the symptoms, expense, stigma, and time commitment, and inconvenience imposed by complicated treatment regimens. To ensure proper, holistic management of pediatric AD, multiple factors must be considered; seasonal changes, lifestyle modifications, and the psychosocial impact are just a couple of factors that require monitoring. What is Known: • Atopic dermatitis impacts patients and their families in quality of life, economically, and psychosocially. • Current treatment revolves largely around treating physical manifestation of disease with first line measures such as topical steroids. What is New: • The holistic management of AD incorporates a good physician-patient relationship, frequent follow-up, and providing structured written plans. • We introduce the house building model for improving treatment adherence. Key points: Pediatric AD can be managed in a more holistic manner which incorporates several factors from the lives of patients and their families. Pediatric patients suffer from many physical and mental comorbidities which should be screened for. Adherence with treatment may be improved by following a model which emphasizes establishing a good physician-patient relationship, frequent follow-up, and providing structured written plans. [ABSTRACT FROM AUTHOR]

Background: Topical retinoids are recommended as the main therapy for most acne patients. Objective: To examine the factors associated with topical retinoid prescriptions for acne. Methods: Retrospective analyses used data from the 2005-2010 National Ambulatory Medical Care Survey (NAMCS) and the 2004-2007 Marketscan Medicaid Database. Multivariate logistic regression models were used to assess the impact of patient and physician factors on the probability of getting a topical retinoid prescription. Results: Results from analyzing the NAMCS data showed that topical retinoids were prescribed in 40.9% of acne-related physician visits. Older age, male gender, and having Medicaid insurance were associated with a lower likelihood of getting a topical retinoid prescription. Moreover, we found in the Medicaid dataset that seeing a pediatrician or family doctor was associated with lower odds of getting a topical retinoid prescription than seeing a dermatologist (OR = 0.24, 95% CI: 0.23, 0.25). Limitations: The available databases do not provide an assessment of the severity of the lesions either at baseline or over time. Conclusion: The frequency of receiving a topical retinoid prescription among acne patients was low and it was associated with age, gender, insurance type and physician specialty. [ABSTRACT FROM AUTHOR]

Background: Pharmacovigilance is a useful to assure the safety of medicines and protect consumers from their harmful effects. Healthcare professionals should consider Adverse Drug Reaction (ADR) reporting as part of their professional obligation and participate in the existent pharmacovigilance programs in their countries. In India, the National PV Program was re-launched in July 2010. Objectives: This survey was conducted in order to assess the knowledge, attitude and practice of Indian pharmacists with the aim of exploring the pharmacists' participation in ADR reporting system, identifying the reasons of under reporting and determining the steps that could be adopted to increase reporting rates. Materials and Methods: A cross-sectional survey was carried out among the pharmacists in India using a pretested questionnaire with 33 questions (10 questions on knowledge, 6 on attitude, 7 on practice, 7 on future of ADR reporting in India and 3 on benefits of reporting ADRs.). The study was conducted, over a period of 3 months from May 2012 to July 2012. Results: Out of the 600 participants to whom the survey was administered, a total of 400 were filled. The response rate of the survey was 67%. 95% responders were knowledgeable about ADRs. 90% participants had a positive attitude towards making ADRs reporting mandatory for practicing pharmacists. 87.5% participants were interested in participating in the National Pharmacovigilance program, in India. 47.5% respondents had observed ADRs in their practice, and 37% had reported it to the national pharmacovigilance center. 92% pharmacists believed reporting ADRs immensely helped in providing quality care to patients. Conclusion: The Indian pharmacists have poor knowledge, attitude, and practice (KAP) towards ADR reporting and pharmacovigilance. Pharmacists with higher qualifications such as the pharmacists with a PharmD have better KAP. With additional training on Pharmacovigilance, the Indian Pharmacists working in different sectors can become part of ADR reporting system. [ABSTRACT FROM AUTHOR]

The problem of patients not taking medications as prescribed, also known as "lack of medication adherence," is widely discussed as an issue related to suboptimal outcomes and excess health care expenditure. Although medication adherence is defined as patients not taking medications as prescribed, there are two elements to it: first, those who fail to follow the medication regimen by skipping a dose or not following the instructions, resulting in poor adherence with prescribed medicines; and, second, the patient who does not take the medication at all or stops after the initial fill. The existing literature contains a lot of studies on the first element, but very little is known about those who stop taking their medication after the initial fill or do not take it at all. In this study, our focus is on identifying patients who fail to refill a prescription for essential medicines, such as asthma-controlling drugs. Using Medicaid claims datasets, this study analyzed a pediatric population diagnosed with persistent asthma that discontinued an essential controlling medication after the initial fill. We found that more than half of this population did not continue their medication after the first fill. While there might be many reasons behind the failure to refill such medications, our data indicate that race/ethnicity, comorbid illness, and type of Medicaid plan are potentially associated with such behavior. Future research is warranted to understand this issue further and identify specific factors causing such behavior, such that strategies may be formulated by which poor adherence can be minimized. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the economic and humanistic burden of chronic sleep maintenance insomnia characterized by nighttime awakenings (CINA). A database analysis of National Health and Wellness Survey, an annual cross-sectional study of health status and outcomes of US adults, was performed. CINA was defined as experiencing nighttime awakenings at least twice per week for more than 1 month that have moderate to severe impact on daily life and not experiencing difficulty falling asleep. No insomnia was defined as not self-reporting insomnia, sleep difficulties, or sleep symptoms. Outcomes included resource utilization in the past 6 months, the Work Productivity and Activity Impairment questionnaire, and the SF-8. Linear regression models were developed to assess the independent effects of CINA on outcomes while controlling for demographics and comorbidity. In all, 1523 respondents met the criteria for CINA and 24,106 met the criteria for no insomnia. Controlling for demographics and comorbidity, CINA sufferers had greater resource utilization (0.1 [ P < 0.001] more emergency room visits, 0.2 [ P = 0.001] more days hospitalized, and 2.5 [ P < 0.001] more provider visits), 22.4% ( P < 0.001) greater activity impairment, and SF-8 physical and mental summary scores that were 6.2 ( P < 0.001) and 6.8 ( P < 0.001) points lower than those with no insomnia, respectively. Among those employed full time, CINA sufferers had greater work productivity impairment (4.0% due to absenteeism, 17.6% due to presenteeism, and 15.6% greater overall productivity impairment) than those with no insomnia ( P < 0.001 for all). CINA in relative isolation was associated with a significant negative impact on health care utilization and its associated costs, health-related quality of life, and work productivity. ( Population Health Management 2010;13:15–20) [ABSTRACT FROM AUTHOR]

This study examined the relationships between SES and diabetes and hypertension for Korean adults using the Korean National Health and Nutritional Examination Survey. To handle the four dummy dependent variables: Diabetes and Hypertension, Diabetes alone, Hypertension alone, and Diabetes or Hypertension, four different logistic models were conducted. The descriptive statistics showed a considerable amount of comorbidity between the combined dependent variable of diabetes and hypertension. To gauge more realistic measures of SES, education and income were combined together as four dummy categories. The SES factor indeed had significant impacts on diabetes and hypertension. Socioeconomically disadvantaged groups demonstrated to have increased likelihood of having these diseases. However, we could not find the strong compensating effect between education and income; the higher level of education but lower income variable was only significant in having both diseases, and the higher income but lower level of education variable was only significant in having hypertension alone and either one of the diseases. Only the highest SES one, the one with a higher level of education and a higher income, was significantly lowering the likelihood of having these diseases in all models. Therefore, public policy and intervention programs should focus on individuals matching these socioeconomic characteristics. [ABSTRACT FROM AUTHOR]

Actinic keratosis is among the most commonly treated skin conditions in the outpatient setting. Its prevalence spans the globe, with greater distribution in fair skinned individuals and the immunocompromised. With high prevalence, increasing incidence and the risk of transformation to a cancerous lesion, prevention and timely treatment present opportunities to rein in costs. The purpose of this article is to review published economic studies relating to the treatment of actinic keratosis, to summarize results discussing the cost drivers of current treatment modalities and to identify parameters most likely to influence the cost effectiveness of treatment. We systematically conducted a published literature search for pharmacoeconomic research of actinic keratosis using title, abstract or full-text searches with the following search terms ([actinic OR solar] AND [keratosis OR keratoses]) AND (economic OR cost OR pharmacoeconomics OR decision). We included published articles referencing actinic keratosis in a standalone study or in a broader study referencing non-melanoma skin cancer and articles evaluating cost-of-illness, cost-of-treatment, cost minimization, cost effectiveness, cost utility, cost-benefit analysis and cost consequence. Our review of the literature found nine studies devoted to pharmacoeconomic considerations of actinic keratosis treatments, with one article investigating both cost-of-illness and cost-of-treatment, two measuring costof- illness, two evaluating cost-of-treatment, one focusing on cost minimization, and three focusing on cost effectiveness. The literature compared a broad range of actinic keratosis treatments including topical medications, cryotherapy, photodynamic therapy, excision and a combination of treatment modalities. The direct cost of actinic keratosis management in the US was estimated at $US1.2 billion per year, with indirect costs totalling $US295 million (year 2004 values). The primary drivers of cost were physician office visits and associated procedures. Pharmacoeconomic research defining standards, outcomes and areas of efficiencies in the treatment of actinic keratosis is in its infancy. To move towards more comprehensive analysis, research needs to focus on updating epidemiological data, evolving evidence-based standards, delineating cost drivers in immunocompetent and immunocompromised populations, and on health outcomes. [ABSTRACT FROM AUTHOR]

This study assessed the need for a ‘very severe (BSA > 20%)’ category for psoriasis. Though impact on quality of life differs between severe (BSA 11–20%) and very severe groups, considerable overlap exists between them. BSA > 10% predicts severity sufficiently, deterring the need for a ‘very severe’ category. Severity was self-assessed and may not reflect true clinical severity. [ABSTRACT FROM AUTHOR]

Background: The clinical effectiveness of carotid endarterectomy (CEA) is well established. But the economic impact of CEA and carotid artery stenting (CAS) is still uncertain. The objective of this study was to compare hospital costs and reimbursement for CAS and CEA. Study Design: We performed a retrospective database analysis on pair-matched patients who underwent CEA (n = 31) and CAS (n = 31) at the Richard M Ross Heart Hospital in Columbus, OH. The hospital’s clinical and financial databases were used to obtain patient-specific information and procedural charges. Cost data were generated by applying the hospital’s ratio of cost to charges for all DRG charges. The Wilcoxon signed-rank test was used to examine the differences between costs of these procedures. Results: Data are reported as mean ± SD. The mean age of patients in CAS group was 70.14 years (± 1.60 years) versus 68.64 years (± 1.75 years) for CEA patients (p < 0.05). The total direct cost associated with CEA ($3,765.12±$2,170.82) was significantly lower than the CAS cost ($8,219.71±$2,958.55, p < 0.001). The mean procedural cost for CAS ($7,543.61±$2,886.54) was significantly higher than that for CEA ($2,720.00±$926.38, p < 0.001). The hospital experienced cost savings of $9,690.87 for CEA versus $4,804.79 for CAS from private insurance. Similarly, savings obtained by Medicare-enrolled CEA patients were higher than those for CAS patients ($1,497.79). Conclusions: CAS is significantly more expensive than CEA, with a major portion of cost attributed to the total procedural cost. The hospital experienced significant savings from CEA procedures compared with CAS under all DRG classifications and insurers. Hospitals must develop new financial strategies and improve the efficiency of infrastructure to make CAS financially viable. [Copyright &y& Elsevier]

Objective: To assess which measures are utilized to quantify lesions, disease severity, and quality of life in the current literature on psoriasis vulgaris. Methods: A MEDLINE search was performed with the keyword 'psoriasis' and the following limits 'All Adult: 19+ years', 'published in the last 5 years', 'English', 'Randomized Controlled Trial', and 'Humans'. The 'Methods' section of the individual articles were reviewed for inclusion criteria that described the study participants' state of psoriasis or disease generalization at baseline, methods used to classify or measure psoriasis during the study, the primary and secondary endpoints, and the quality of life measures utilized in each study. Results: A search resulted in a total of 180 articles, out of which 134 were utilized for the review. The criteria most commonly utilized were 'moderate to severe psoriasis', 'BSA ≥10%', 'mild to moderate psoriasis', and 'severe psoriasis'. PASI was the most commonly used measure to describe the extent of psoriasis. The most common QoL measure used was DLQI, being used in 54.8% of the articles that used some form of QoL measure/s. Discussion: Various measures are being utilized for the same purpose of generalizing disease/lesion severity and determining 'quality of life'. [ABSTRACT FROM AUTHOR]